Implementation of the nursing process in a health area: models and assessment structures used

OBJECTIVE: to analyze what nursing models and nursing assessment structures have been used in the implementation of the nursing process at the public and private centers in the health area Gipuzkoa (Basque Country). METHOD: a retrospective study was undertaken, based on the analysis of the nursing records used at the 158 centers studied. RESULTS: the Henderson model, Carpenito's bifocal structure, Gordon's assessment structure and the Resident Assessment Instrument Nursing Home 2.0 have been used as nursing models and assessment structures to implement the nursing process. At some centers, the selected model or assessment structure has varied over time. CONCLUSION: Henderson's model has been the most used to implement the nursing process. Furthermore, the trend is observed to complement or replace Henderson's model by nursing assessment structures.


Introduction
The nursing process is the work method used in nursing and permits, through research, logical analysis and analytic reasoning, the development and application of technical, interpersonal or relational and communication care. It involves five steps: assessment, diagnosis, planning, execution and, finally, evaluation (1) .
Its creation dates back to the 1950-1960's in the United States of America and Canada (2) . In the initial years, it is mainly discussed and developed in teaching. In the 1970's, it is extended to clinical practice (professional practice) in those countries and continues developing. The establishment of the nursing diagnoses and NIC-NOC terminologies are steps that stand out in this development. Nowadays, the nursing process is used at health centers all over the world (3)(4) .
In the same decades as the creation and the implementation of the nursing process, models and theories are established that serve as a guide for professional nursing practice (5) . While the nursing process is a method to organize professional practice, the nursing models and theories are a framework to understand and give meaning to this professional practice, which guarantees a strict practice based on personal experience and on the scientific and philosophical premises each theorist contributes. Therefore, one should depart from general philosophical and scientific elements that will transform into concrete and unique elements, which will serve to define the empirical and operative elements of each conceptual model. In that sense, the nursing guides or models used condition the practice, which rests on the theoretical foundations each model contains and which the nurses identify with, accepting that the clients and their own reality are conditioned by the underlying theoretical base (6) .
In general, one might say that the nursing models and theories help to identify the objectives and practice means each person is provided with (7) . To give an example, when adopting the Henderson model, the nurses accept the proposal to satisfy the patients' needs and aim to generate the independence of each person.
If they prefer Orem's model, they will aim to maximize the clients' self-care skills (6) .
Later, without reaching the point of being models or theories, different nursing assessment structures are published, including Carpenito's bifocal structure (8) and Gordon's conceptual structure (9) . The bifocal structure Carpenito introduced in 1983 is a model in which the clinical situations are identified in which the nurse intervenes, making reference to independent nursing work and interdependent or collaborative work.
Gordon's conceptual structure serves as a general reference framework to assess each person through the proposed Functional Health Patterns. After obtaining Gordon's permission and after being modified by NANDA International's taxonomy committee, the NANDA accepted this structure in April 1998 (10) .
Few studies (11)(12)  criterion followed to consider that the nursing process is applied, as the rest of the nursing process phases rest on the first (1,13) .
-The shape of the nursing assessment records used at the center over time. To determine what nursing model and/or what assessment structure were used, it was verified that the shape of the records corresponds to the guidelines that mark one or another model or structure. To give an example, it was considered that Henderson's model was used if the assessment records address at least 75% of the basic needs presented in that model (14) . In another example, it was considered that Gordon's assessment structure was used if at least 75% of the functional patterns this structure rests on were assessed.
Quantitative analysis was applied to the data, using descriptive statistics.

Results
In Table 1, the centers studied are shown, as well as the number of nursing professionals, the year the application of the nursing process (NP) started, the nursing model or assessment structure used in the application of the nursing process and the year this nursing model or assessment structure started to be used. When the cell is empty, this means that the above are not used at the center. The number of nursing professionals working at each center reveals its size. Huitzi-Egilegor JX, Elorza-Puyadena MI, Urkia-Etxabe JM, Asurabarrena-Iraola C.
According to the figures in Table 1, besides some exception, the use of the nursing process starts in 1990 and is generalized in the first decade of the 21 st century. Nowadays, at 155 (98%) out of the 158 centers studied, the nursing process is applied. It is applied at all public centers and 18 out of 21 private centers.
The details of this start are available for one public center and 18 out of 21 private centers. These details are available in a previously published retrospective study (15) , and the details of the current use (the use of the nursing diagnoses, the NIC-NOC terminologies and the standardized care plans) in an also published crosssectional study (12) .
At 127 (82%) out of the 155 centers that apply the nursing process, Henderson's model is used; at six (4%) Carpenito's bifocal structure is used; at 17 (11%) Gordon's conceptual structure and, at one, the RAI-NH

Discussion
The results show that, in Gipuzkoa, Henderson's model has been the most used in the implementation of the nursing process. That is in accordance with the authors who refer that Henderson's model is one of the most well-known and globally used models (5,16) .

The usage figures obtained in this study, superior
to 80% in the case of Henderson's model, is higher than the figures obtained in other similar studies. In a study undertaken in Spain, it is affirmed that, in primary care, 35% of the centers use Henderson's model, which is the only one used (11) . In a study undertaken in Canada, it was found that only 25.5% of the centers use a nursing model to apply the nursing process (17) . The study does not specify what nursing models are used. In another study developed in Poland, it is concluded that, in that country's clinical practice, the ideas and theories of Nightingale, Orem and Henderson are used, but the study does not quantify this use per centers (18) .
In general, in Gipuzkoa, the nursing process is applied under the influence of a nursing model or theory.
Concerning the activity area, as mentioned, Gordon's conceptual structure is mainly used in the mental sector. This can be due to the fact that the school in the Basque Country that offers the programs to obtain the degree of mental health nursing specialist has selected this structure.
As regards the geriatric area, it should be observed that, at the public as well as the private centers, in the nursing assessment records, a paragraph was found in which the patients' ability to accomplish the activities of daily living is assessed. This term "activities of daily living" reminds of the term "activities of living" in the nursing model by Roper-Logan-Tierney (22) but, in the records studied, the 12 activities of living this model proposes are not assessed, but only those activities that propose the indices used to measure the autonomy in the accomplishment of the activities of daily living (Katz, Barthel and Lawton indices). That is the reason why it was not considered that this nursing model is applied.
Finally, it is noteworthy that, at almost all public centers in the same area, the selected assessment model or structure coincides and is simultaneous over time. At the private centers, on the other hand, there are differences in the choice of the model or assessment structure as well as in the start date. That is so because, at the public centers, the management of each area, which drives the changes, is unified. The management at the private centers, on the other hand, is independent, without any connections among them.

Conclusions
These study results show that, in Gipuzkoa, Henderson's model has been the most used in the implementation of the nursing process.
Over time, a trend is observed to complement or replace Henderson's model by nursing assessment structures.
Finally, this study reveals that, at the public centers in the same area, the nursing model or assessment structure almost always coincides, which is not the case at the private centers.